Neurosurgery Coding Alert

As stated in the descriptors, these procedures may be unilateral or bilateral, and the same code, with no modifiers appended, is appropriate whether the surgeon removes one or both lamina of a particular vertebra. If the surgeon removes lamina from more than one vertebra, report each additional level using +63048 (... each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]), Bucholz says.

Laminotomy, also known as hemilaminectomy, involves removal of the upper and lower portions of adjacent laminae (i.e., the laminae on either side of a vertebral interspace) rather than the removal of the entire lamina(ae) of a single vertebra, as described by laminectomy. CPT contains seven codes to report laminotomy:

Report an initial laminotomy using 63020 or 63030, depending on location, with +63035 for each additional level beyond the first. Report re-exploration using 63040 or 63042 (again, depending on location). Code +63043 should accompany 63040 only for each additional level, while +63044 should accompany 63042.

Unlike laminectomy codes 63045-63048, laminotomy codes are exclusively unilateral. Therefore, if the surgeon performs the procedure bilaterally, modifier -50 (Bilateral procedure) may be appended and reimbursement should be automatically adjusted upward, says Gregory J. Przybylski, MD, AMA RUC member representing the American Association of Neurological Surgeons. Payment for codes appended with modifier -50 is generally increased to 150 percent of the standard amount. This applies to both the primary procedure codes (63030, 63040 and 63042) and their associated add-on codes (63035, 63043 and 63044, respectively).

For example, the surgeon removes the lower portion of the right lamina at C4, the upper and lower portions of the right lamina at C5, and the upper-right portion of lamina at C6 during an initial exploration. In this case, appropriate coding is 63020 (for the laminotomy of adjacent segments C4 and C5), 63035 (for laminotomy at the additional interspace C5/C6).

In a second example, the surgeon excises the lower portion of L1 on both the right and left, the upper and lower portions of L2 on both the right and left, and the upper portion of L3 on the right and left during a reexploration. In this case, report 63042-50 (for bilateral laminotomy at L1/L2 interspace) and 63044-50 (for bilateral laminotomy at the additional interspace L2/L3). If the surgeon had extended the surgery to include the L3/L4 interspace, you could report an additional unit of 63044. You need not report modifier -51 (Multiple procedures) for any add-on codes in the above examples.

In past years Medicare carriers considered 63040 and 63042 "regional" procedures and did not recognize +63043 or +63044. For 2002, however, these codes were assigned a C status indicator, meaning they are "carrier-priced codes" (i.e., individual carriers will establish relative value unit and payment amounts for these services, "generally on a case-by-case basis following review of documentation, such as an operative report," according to CMS) and separate payment will be allowed. Although surgeons can expect widely varying reimbursement depending on the carrier, they should report +63043/+63044 and expect payment when the codes are applicable. If the payer refuses the claim, appeal, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, noting that prior to 2001 billing for "each additional" level with 63042-51 (Multiple procedures) was allowed.

If the surgeon extends a bilateral or unilateral cervical laminectomy significantly above or below the targeted segment to remove part of an adjacent segment and performs a diskectomy, you may report both the laminectomy and the laminotomy by appending modifiers -51 and -59 (Distinct procedural service) to indicate that the laminotomy was a separate, required procedure. As stated in CPT Assistant (February 2001), "If both a laminectomy and a laminotomy are performed on the spine at different levels, then it would be appropriate to report a separate code for each of the procedures."

For example, the surgeon removes the left lamina of segment C5, the left and right lamina of segment C6, and the right lamina of segment C7. In addition, he or she removes a significant portion of the lower left lamina of segment C4 to ease access for a diskectomy at C4/C5. To report the service, assign 63045 (for the unilateral laminectomy at C4), 63048 x 2 (for the bilateral laminectomy at C6 and unilateral laminectomy at C7), 63030-51-59 (for the laminotomy with diskectomy at C4/C5).

Note: Alternatively, you may append modifier -22 (Unusual procedural services) to the appropriate laminectomy code to identify the procedure as more extensive than usual and forgo reporting the laminotomy. In this case, coding for the above example is 63045-22, 63048 x 2. Be sure to include supporting documentation to justify the claim, along with a request for additional reimbursement commensurate with the increased effort.

When billing for laminectomies and laminotomies, include a detailed operative report that explains the patient's condition prior to and during surgery, i.e., an appropriate diagnosis(es). For laminectomy, be sure to stress that the surgeon removed entirely one or both lamina of the targeted vertebrae. For laminotomy, note that the surgeon removed only a portion of the laminae on either side of a vertebral interspace and explicitly define the procedure as bilateral (when appropriate) by noting that both the left and right laminae were removed.